Integrating Co-Occurring Disorders Treatment for Clients Who Do Not Have a History of Substance Abuse / Dependence Treatment

Transcription

1 Integrating Co-Occurring Disorders Treatment for Clients Who Do Not Have a History of Substance Abuse / Dependence Treatment Clients may have negative stereotypes about the words substance abuse, addiction, addict, etc. Use this as an opportunity to educate the client. Remember that, according to the Triad of Change, clients may be in a different Stage of Change in terms of their substance-use / dependence needs than they are in terms of their mental health needs (for example, a client may be very motivated for their mental health treatment, but may not be aware or their substance-related needs or may only be starting explore their options). NOTE! It is critical to always validate the reason for a client s question or response and the feelings that may go along with it. Some Ways to Talk About the Referral ** Integration depends on whether you are a COD Practitioner, part of a COD Team, or provide linkage with substance abuse treatment ** Examples by Level of Integration: Integrated COD Treatment (with COD Practitioner): I d like to follow up and talk with you about some of the things that I have been hearing you talk about. In particular, XXXX These are issues that we can integrate into our work together Integrated COD Treatment (with COD Team): I d like to make a referral for you to meet with my teammate for a substance use evaluation and discuss the options that you have available to you Linked Treatment (treatment in different programs): I d like to make a referral for you to meet a colleague for an evaluation of your level of substance use and discuss the options that you have available to you Other examples: Based upon what you have been telling me, I have the sense that you have a lot of things going on in addition to your mental health issues. I d like to refer you to a counselor colleague of mine who can make a more comprehensive evaluation of your needs. The things that s/he will evaluate will include I want to refer you to a colleague of mine who can explore whether we could provide additional services for you. Specifically, I am hearing that you may be using or relying on drugs or alcohol and we would be in a great position to help you with that We are very fortunate because we can provide substance abuse services in addition to mental health services. This is because we know that we are most likely to succeed if we offer services that address the whole person and don t only focus on the mental health issues A.J. Porteus, PhD 1 of 5

2 Common Responses to the Referral, and Some Suggested Ways of Replying to Clients Table of Contents: I m just taking the edge off my mental illness... 2 What medications are there for substance abuse / addictions treatment?... 3 Those people in AOD treatment have a problem with my taking medication they think it s a cop out... 3 Sometimes I feel overwhelmed and need to take breaks, but they won t let me in my program?... 4 How do I deal with all of the people and all of the groups?... 4 Why doesn t my regular counselor tell me about herself?... 5 Mandated Treatment / Sanctions/ Personal Responsibility... 5 I m just taking the edge off my mental illness 1. Validate the Reason: The client is reporting self medication which suggests insight into symptoms (MH) and motivation to get symptom relief (through substance use). 2. Validate the Feeling: Common feelings include: Confusion; resentment (that the issue has been raised); fear of judgment ( immorality, etc); fear that there will be some need to change behaviours. a. It sounds like you are self medicating, that your illness makes you feel a certain way and you find that using XXX helps deal with those symptoms, am I right? b. My sense is that, by using XXX, you have found something that works for you. That s a pretty major step for you given how negatively your mental health issues effect you c. I think I hear what you are saying that you are using XXX to help manage your illness I guess what I would say to that is that I would like to compare XXX and it s positive and negative side effects to legal medications and other types of treatment (like talk therapy ) and the positive and negative side effects that they have. d. I hear what you are saying and commend your insight that you have been self medicating to address your mental health issues. However, at this point it sounds like you (1) have to use more XXX to get the same effect (2) experience withdrawal when you do not use (3) are having relationship / family problems as a result of your use, and this suggests to me that we need to address your self medication. A.J. Porteus, PhD 2 of 5

3 What medications are there for substance abuse / addictions treatment? 1. Validate the Reason: The fact that client is willing to explore treatment options for substance abuse / dependence. Note client s vantage point (pharmacological vs. other interventions). 2. Validate the Feeling: Common feelings include: Concern (increased Rx) a. Yes, there are medications that are used with different types of substance abuse and dependence, although they are not always designed with the specific goal of treating substance-abuse / dependence. b. That s a great question I really appreciate your willingness to explore treatment options. c. Self Medication Hypothesis: sounds like you see this as something you can treat, and maybe you ve sees your use of XXX in the past as a way of medicating yourself. Those people in AOD treatment have a problem with my taking medication they think it s a cop out 1. Validate the Reason: If this is your first time talking about this, then the client is showing some understanding of how substance abuse treatment works. 2. Validate the Feeling: Common feelings include: Experiencing stigma; Fear (that medication could be discontinued); Not being understood; etc **This issue is more a matter folklore than reality at this point, unless you get a particularly old school group (and those are usually closed groups). However, clients still often report feeling less than because they are taking medications** a. It must be anxiety-provoking to go to a meeting with the hope of getting support, only to be confronted for your efforts to stabilize your mental health issues. b. Could we look into whether there are any other groups that may be more supportive? One suggestion would be to try Dual Recovery Anonymous (DRA) c. [For clients who are able to represent themselves] This may be one of those times when you have to do a little education. For all you know there may be other people in the group with similar issues and your comments may help them speak up A.J. Porteus, PhD 3 of 5

4 Sometimes I feel overwhelmed and need to take breaks, but they won t let me in my program? 1. Validate the Reason: The client obviously has insight into his / her capacity to tolerate stimulation and know when s/he would benefit from a break. Validate the insight and the intention ie to regain a mental state in which s/he can participate in treatment 2. Validate the Feeling: Common feelings include: Guilt (not wanting to ask for something that others can t get); Embarrassment (being treated like weak or unable to tolerate the program; etc ** the Evidence Based Practice for residential COD treatment incorporates the Modified Therapeutic Community (TC). One substantial modification is that individuals with mental health issues are allowed to take time off the floor as needed. Over time, clients become increasingly insightful and articulate about managing their issues.** a. I m really struck by the way in which you are trying manage your mental health issues so that you can maximize your engagement in AOD treatment. b. Would it be OK for me to talk with my colleagues in your program and see if we can arrange for you to have time out when you need it c. I know from some colleagues that people use their need for time out to actually avoid being in treatment. I wonder what the reaction would be if we addressed that with staff? How do I deal with all of the people and all of the groups? 1. Validate the Reason: The client is concerned about her/his ability to function in groups. This is often a good insight, and the client also appears to know something about treatment 2. Validate the Feeling: Common feelings include: Fear (overstimulation, paranoia / suspicion); Embarrassment; etc. 4. Respond with some of the following options: **Substance abuse treatment places a heavy emphasis on group interventions. Clients whose customary care has been in mental health are often not used to this level of group engagement, require time to become primed for group treatment, and may require accommodations (eg time outs)** a. That s a good point and you obviously know a thing or two about substance abuse treatment. Since you sometimes have a hard time in crowds, maybe we should work on ways that would allow you to attend the groups and get something out of them b. [if the groups is in-house and facilitated by the same person] Let s work on that. I know that this presents a challenge, I know that you could benefit from attending the groups, and I know that we could explore ways that would allow you to get the most out of them. c. [if the groups is in-house but facilitated by another person] Maybe I can talk with the group facilitator in our team meeting and explore possibilities for getting you geared up for group d. [if the groups is located elsewhere] Maybe I can talk with the group facilitator and explore possibilities for getting you geared up for group A.J. Porteus, PhD 4 of 5

5 Why doesn t my regular counselor tell me about herself? 1. Validate the Reason: The client is identifying differences in treatment professionals. This usually indicates the strength of the relationship and the client s observation of his / her own treatment process. 2. Validate the Feeling: Common feelings include: Feelings related to attachment; **Personal disclosure on the part of the Counselor is more prevalent in substance abuse treatment than in mental health treatment. Clients accustomed to disclosure or non-disclosure often experience the difference between counselor, and may wonder why one is disclosing more than the other** a. That s a really good observation. Counselors are more likely to talk about their own experience depending on the type of services that they are delivering. In some places, like substance abuse treatment, counselors may run their story as a way of having everyone get on the same page. In others, counselors may ask clients to talk more about themselves so that the clients build a sense of connectedness in a group. b. [for clients who like more disclosure] It sounds like you like that. It can be a good way of getting everyone on the same page and letting you feel understood. c. [for clients who want more disclosure] It sounds like you would like me / your other counselor to reflect upon our own experience more. I d like to know more about how that would help you d. [for clients who want less disclosure] It sounds like you would prefer less personal disclosure from your counselor / me. Mandated Treatment / Sanctions/ Personal Responsibility Unless clients are familiar with Mental Health Court, clients with a history of mental illness who are mandated to substance abuse treatment are not familiar with compulsory treatment. For those with pre-existing paranoia or high suspicion, this can be particularly distressing. Currently, unless mandated by Mental Health Court or Welfare and Institutions Codes, a client with mental health issues cannot be treated under duress. Important issues to touch upon are: Extent to which mental health records will be released What are the qualifications of the person(s) scrutinizing clinical records Whether or not individuals who have the right to look at substance abuse treatment records will have access to mental health records Assessment of personal responsibility Rx compliance Attendance Continued substance use A.J. Porteus, PhD 5 of 5